Madness in Civilisation: A Cultural History of Insanity
By Andrew Scull: London, Thames & Hudson.
448 pages. 128 Illustrations (44 colour).
ISBN 978 0 500 252123
Until recently the history of psychiatry was a neglected backwater whose murky depths were explored largely by psychiatrist. The impression conveyed by books such as Tuke’s Chapters in the History of the Insane in the British Isles,1 Macalpine and Hunter’s Three Hundred Years of Psychiatry: 1535 – 1860,2 Berrios and Freemen’s 150 Years of British Psychiatry 1841 – 1991,3 or Fuller Torrey and Miller’s The Invisible Plague,4 is one that sees psychiatry and modern systems of mental health care as the inevitable outcome of progress through scientific thought, a (white European male-led) narrative from darkness and ignorance to enlightenment and knowledge. Indeed, when as a trainee, I made so bold as to question a consultant I was working with about this history, I was mildly rebuked for my impertinence. ‘Psychiatry is simply the outcome of two hundred years of scientific thought’ I was told. ‘It just happened that way. It’s not our place to question it.’
Nearly forty years on and how the world has changed. Allan Beveridge, a psychiatrist more familiar than most with the vagaries of the history of psychiatry, points out that two books changed the way we see the field: Michel Foucault’s Madness and Civilization5 and Andrew Scull’s Museums of Madness.6 In featuring the word ‘madness’ in their titles they invite us to view psychiatry not as a flower of the Enlightenment, something that emerged as though through natural laws, or as an inevitable consequence of the application of reason, but as an oppressive regime that silenced madness, incarcerated it and visited upon it untold horrors under the guise of treatment.
There is no denying the importance of these two books, both of which had a profound influence on my own thought and practice as a psychiatrist. They marked a turning point, a revolution in the way that we think about psychiatry today. Foucault has always defied categorisation, scholar and intellectual, historian, philosopher, cultural critic. This of course makes him an easy target of attack for those who snipe at him, ensconced securely behind the walls of their own academic disciplines. Scull is a sociologist who followed post-doctoral studies in the history of medicine at University College London. These two books were published when the history of psychiatry was opening up to authors from a wide range of disciplines, historians (Jones7 and Porter8,9), social anthropologists (Skultans10), feminist writers (Showalter,11 Appignanesi12), philosophers (Hacking13,14) and those writing from a Marxist perspective (Doerner,15 and to a point, Scull6). These accounts challenge the view that psychiatry grew out of scientific progress. Instead they direct attention at the historical, economic, cultural and political conditions that made it possible for the discipline of psychiatry to emerge in the first place.
Museums of Madness was my first encounter with Scull’s work. It argues that the move to asylum care in nineteenth century Britain can best be understood as the response of an early capitalist economy to the growing problems of those members of society who were unable to fulfil a ‘productive’ role. I read the book at about the same time as Foucault’s Madness and Civilization. From the perspective of a budding critical psychiatrist I was more influenced by Foucault’s work, especially the view of the ambiguous and polar nature of power in shaping our subjectivities that emerged in his later work. Pat Bracken and I16 drew less inspiration from Museums of Madness and Madness and Civilization, (a book I struggled with until I read Jonathan Murphy and Jean Khalfa’s excellent re-translation ) than we did from Foucault’s later analyses of power.18
Nevertheless, I was intrigued when Robert Whitaker asked would I review Andrew Scull’s latest book for Mad in America. I jumped at the opportunity, keen to discover what Scull had to say more than 35 years after his earlier work.
The scope of Madness in Civilization is impressive. Scull’s impeccable scholarship transports us from demons and antiquity to DSM5 and antipsychiatry in twelve beautifully written chapters. Its style is engaging, making it both entertaining, thought provoking and accessible to readers from many different backgrounds. Although its price tag may seem excessive (£28 in UK, $39.50 US), I would argue that this is a reasonable price for a lengthy hardback with many illustrations. It would probably be two or three times more expensive with some other publishers.
The early chapters cover madness in the world of the Old Testament, Classical Greece and Rome. Scull points out that although the medicine of Hippocrates was a rational practice based in humoral theories of disease within the physical body, this co-existed alongside the cult of Asklepius, whose rituals were based in cultural and supernatural understandings shared between supplicants and priests.19 Chapter 3 sets out the role of Islam in preserving and enriching the science and art of medicine of Classical Greece, as Europe marched into the Dark Ages after the fall of the Roman Empire. Islamic scholarship kept alive knowledge and understanding from Hellenic and Roman thought, as well as infusing it with other influences, especially the Ayurvedic and Chinese traditions of medicine.
From chapter 5 on, and through to the end of the book three themes emerge in Scull’s account of the place of madness in civilisation at different points in history. These concern changing representations of madness in art, literature and music; the terrifying and abusive nature of things done to the mad by physicians under the guise of ‘treatment’; and the role of what might broadly be described as non-specific factors in helping people who experience madness.
The different ways in which madness and the mad have been represented in the humanities is an important and recurring theme throughout the book. Chapter 4 sees the Shakespearean characters Lady Macbeth, Hamlet and Ophelia, as people whose madness originates in the fierceness of their passions. Chapter 5 considers Walter Scott’s novel The Bride of Lammermoor a story that reached a wide audience through Donizetti’s opera Lucia di Lammermoor. Lucia’s madness is seen as the response of a woman who is forced into an unwanted marriage. In the twentieth century (chapter 11) Scull examines the ways in which madness is portrayed in the operas of Benjamin Britten and the plays of Tennessee Williams. Britten’s opera Peter Grimes reinvigorated the tradition of English opera that died with Henry Purcell 250 years earlier, but it was also a powerful portrayal of madness in opera, alongside Alban Berg’s Wozzeck. Peter Grimes is the lone Suffolk fisherman, whose abusive treatment of his apprentices ostracises him from the community. Rejected and despised by the villagers, he is driven into madness and a watery grave. Tennessee Williams’ character Blanche Dubois in A Streetcar Named Desire, is a tragic woman whose infidelity leads her into a life of abusive relationships, promiscuity, rape, alcoholism and finally the asylum. The liminal nature of madness is, as Scull observes, reflected in the transgressive nature of the creative work of both men and their lives – both were openly gay at a time when the values of society made it all but impossible for men to acknowledge this aspect of their sexuality.
The second theme concerns the abusive and harmful nature of the interventions suffered by the mad under the guise of treatment throughout history. For example, from the late 18th century on (chapter 5) we see the use of various forms of water torture, Benjamin Rush’s tranquilising chair, and Erasmus Darwin’s (Charles Darwin’s grandfather) swinging chair. Scull identifies the origin of these systems of torture and corporal punishment to the 18th century view that mad people being bereft of reason, were little more than irrational brutes in need of firm discipline and control.
The third theme concerns the role of non-specific or non-technological factors in helping the insane. These are aspects of care that are not grounded in any specific theories about the nature of madness, but in the quality of the relationship between the mad person and physician, and the hope and meaning that this relationship conveys, a feature that is symbolised by the placebo response.20 The use of non-specific factors emerges in the earliest accounts of madness, for example in chapter 1 the harp music played by David to appease the evil spirit with which God smote Saul. In chapter 6 we see that Thomas Willis, regarded by many as a key seventeenth century figure in the pre-history of psychiatry, urged the use of ‘flattery’ to cure the aristocratic, wealthy, and fashionable who suffered from milder forms of nervous disorders. For those of more ‘refined’ and ‘delicate’ sensibilities soothing and calming remedies were much more likely to be effective than the violent interventions imposed on those suffering from the more extreme forms of Bedlam madness.
The first person singular of the Latin verb placere – I please (or flatter) – provides the root of our word placebo. In the nineteenth century the word came to be used by physicians to apply to any medication used to please rather than benefit the patient. The placebo response remains an important factor in the treatment of depression and anxiety. The quality of the therapeutic relationship was also an important feature of moral management, with its emphasis on treating the mad with respect and dignity.
As I immersed myself in Madness in Civilization I became aware of a deeper current running beneath its surface. What emerges from Scull’s history is the extent to which our responses to madness have swung like a pendulum between two extremes at different points in history. This is the clearest indication that the history of psychiatry is anything but an orderly and progressive march. Instead it seems that since the seventeenth century we have swung from what might broadly be called somatic or biological explanations of madness to the humanistic and moral.
The brutal somatic treatment of the insane in the eighteenth century madhouses, with its whirling chairs, beatings, purges, blood-letting and ducking stools, gave way at the dawn of the 19th century to moral management, and a concern for what today would be called the human rights of the mad, the importance of the values of respect and dignity, and of pleasant surroundings in aiding recovery. But the hope and optimism that this innovation introduced faded as the Victorian asylums increased in size and number through the nineteenth century. In turn it gave way to a mood of hopelessness and despair, as a negative view gained ground that madness was inherently incurable and refractory. This wasn’t, however, a failure to be laid at the door of psychiatry; it had to do with the very nature of insanity. In the second half of the nineteenth century Scull describes the rise of the cultural trope of degeneration, which can be seen in late nineteenth century literature, for example Zola’s Rougon-Macquart novels.
As far as madness is concerned, degeneration became a pessimistic discourse of otherness; it represented the polar opposite of the Enlightenment ideal of progress. In medicine it was defined in terms of a hereditary taint or weakness, a self-duplicating pathological process that corroded Weismann’s germ plasm and the blood stock of the race. Degeneration became the lowest common denominator for a wide range of complex problems – madness, alcoholism, cretinism and syphilis, as well as the problems of the peasantry and urban poor, of anarchism and feminism.21 It also surfaced in the racial science that emerged in the early twentieth century, and the baleful and malevolent legacy that this bequeathed.
The next oscillation of the pendulum brings us into the twentieth century. Habituated to the mechanised horrors and bloody slaughter of the First World War (which Scull evokes powerfully through the poetry of Wilfred Owen and others) it seems that something snapped in the moral compass of psychiatry. Its determination to vanquish the stubborn resistance of madness became so intense that anything became justifiable in the name of treatment. After the mass insanity of the First World War, the mad were subjected to the most barbaric and horrific interventions, the surgical interventions of Henry Cotton, Wagner-Jauregg’s malarial therapy, insulin coma therapy, shock therapy, Freeman and lobotomy. The great conceit, the view that psychiatry is simply a medicine of the brain, shattered the bodies and souls of the insane.
After the Second World War the pendulum swung back again. The therapeutic community movement (to which Scull surprisingly makes no reference) recalled the tradition of moral management, albeit with the imperious gaze and power of the physician replaced by the pressure of one’s peers to conform. The rise of psychoanalysis in the USA (and France too) suggested that far from being ignorant brutes, the mad were simply those of us who were misled and fooled by the tricks of our own minds, as we desperately tried to avoid the retelling of painful stories from our pasts. All we needed was a secure relationship in which to tell our stories – as long as we could afford to pay for it.
Then along came a little yellow pill…
In her review essay of Museums of Madness, Kathleen Jones drew attention to what she called Scull’s dilemma. She wrote
‘…if it is wrong to get patients out of the mental hospital, and wrong to keep them in, what are we to do with them?’ (1982:221, my emphasis)
The answer to this question is to be found in two images that Andrew Scull uses in Madness in Civilization. They symbolise the moral argument that lies at the heart of his book. The first is to be found on page 317, taken from the second edition of Freeman and Watt’s book, Psychosurgery. It shows a naked female patient being restrained and manhandled by two nurses as she mounts a futile attempt to resist being taken down for lobotomy. The second image, on page 366, is that of the male incontinence ward in Byberry State Hospital in 1944. The journalist Albert Deutsch brought the appalling conditions in this forgotten corner of Pennsylvania to the attention of the American people in his book The Shame of the States.22 In the picture we see naked, wraith-like figures leaning against the walls, and wandering aimlessly through the vast emptiness of the ward. This is a scene reminiscent of Goya’s Yard with Lunatics, which features on the cover of Foucault’s History of Madness.17
At the heart of Scull’s compassionate masterpiece is the view that the lesson of history is not what we should do to the mad, nor what we should do with them. The lesson is that to ask such questions is to miss the point. Before we ask questions or do anything, our primary responsibility is to see the mad person not as an other but as ourselves. Only then may it be possible to break free of the tragic wheel of misfortune which we have bound the mad and ourselves over the last 250 years.
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1. Tuke D. Chapters in the History of the Insane in the British Isles. London, Kegan Paul, Trench & Co, 1882.
2. Macalpine. I. and Hunter, R. Three Hundred Years of Psychiatry. 1535–1860. A history presented in selected English texts. London, Oxford University Press. 1963
3. Berrios, G. & Freeman, H. (eds.) 150 Years of British Psychiatry 1841 – 1991 London, Gaskell. 1991
4. Fuller Torrey, E. & Miller, J. The Invisible Plague: The Rise of Mental Illness from 1750 to the Present. New Brunswick, Rutgers University Press. 2001
5. Foucault, M. Madness and Civilization: A History of Insanity in the Age of Reason. London, Routledge (trans. R. Howard, originally published as Histoire de la Folie , Paris, Librairie Plion, 1961) 1971
6. Scull, A, Museums of Madness: the social organisation of insanity in 19th century England, London, Allen Lane 1979
7. Jones, K. A History of the Mental Health Services. London, Routledge and Kegan Paul. 1972
8. Porter, R. Madness: A Brief History. Oxford, Oxford University Press. 2002
9. Porter, R. Madmen: A Social History of Mad-houses, Mad-doctors and Lunatics Stroud, Tempus. 2006
10. Skultans, V. English Madness: Ideas on Onsanity 1580 – 1890. London, Routledge & Kegan Paul 1979.
11. Showalter, E. The Female Malady: Women, Madness and English Culture , 1830 – 1980. London, Virago 1987
12. Appignanesi L. Mad, Bad and Sad: A History of Women and the Mind Doctors from 1800 to the Present. London, Virago, 2008.
13. Hacking, I. Rewriting the Soul: Multiple Personality and the Sciences of Memory. Princeton, Princeton University Press 1995.
14. Hacking, I. Mad Travellers: Reflections on the Reality of Transient Mental Illnesses. Cambridge, Mass. Harvard University Press. 2002
15. Doerner, K. Madmen and the Bourgeoisie: A Social History of Insanity and Psychiatry Oxford, Basil Blackwell 1981.
16. Bracken, P. & Thomas, P. From Szasz to Foucault. On the Role of Critical Psychiatry. Philosophy, Psychiatry and Psychology, 17, 3, 219-228. 2010
17. Foucault, M. History of Madness (ed J. Khalfa, trans. J. Murphy and J. Khalfa) London, Routledge. 2006
18. Foucault, M. Afterword, in Michel Foucault: Beyond Structuralism and Hermeneutics (eds H. Dreyfus and P. Rabinow) New York, Harvester Wheatsheaf. 1982
19. Rynearson, N. Constructing and Deconstructing the Body in the Cult of Asklepios. Stanford Journal of Archaeology, 2, Accessed at on 9th April 2015 at http://web.stanford.edu/dept/archaeology/journal/newdraft/2003_Journal/rynearson/paper.pdf
20. Moerman, D. Meaning, medicine and the ‘placebo effect.’ Cambridge: Cambridge University Press. 2002
21. Pick, D. Faces of Degeneration: A European Disorder, c. 1848 – c. 1918. Cambridge University Press. 1989
22. Deutsch, A. The Shame of the States. New York, Harcourt Brace 1948.